Overview
Three systems are foundational to provider credentialing and payer enrollment in the United States:
NPI — National Provider Identifier, issued by CMS, required to bill any healthcare insurance in the US.
CAQH ProView — A centralized credentialing database used by most commercial payers to retrieve provider information during the enrollment process.
PECOS — Provider Enrollment, Chain, and Ownership System, the CMS system used for Medicare enrollment.
Every provider who bills insurance needs an NPI. Most providers who bill commercial insurance need an active, attested CAQH profile. All providers who bill Medicare must complete enrollment through PECOS.
These three systems are not the same thing, do not replace each other, and require separate setup and maintenance.
What Is an NPI?
The National Provider Identifier (NPI) is a unique 10-digit identification number assigned to healthcare providers by the Centers for Medicare & Medicaid Services (CMS).
There are two types of NPIs:
Type 1 NPI (Individual Provider): Assigned to individual healthcare providers — physicians, NPs, PAs, therapists, dentists, etc. Each individual provider has one Type 1 NPI that stays with them regardless of where they practice.
Type 2 NPI (Organizational): Assigned to organizations, group practices, and facilities. A medical group, clinic, or practice entity has a Type 2 NPI.
How to obtain an NPI:
Apply through the National Plan & Provider Enumeration System (NPPES) at nppes.cms.hhs.gov. The process is free and typically takes a few days.
Why NPI records matter for enrollment:
The information in your NPPES record — taxonomy code (specialty), address, and business information — must match what you submit to payers. Inconsistencies between your NPPES record and your enrollment applications are a common cause of rejection.
Key NPI maintenance tasks:
- •Update your NPPES record when you change your practice location
- •Verify your taxonomy code accurately reflects your specialty
- •Keep your authorized official and contact information current
- •Add your Type 2 NPI as a sub-part of the group entity when required
What Is CAQH?
CAQH ProView (Council for Affordable Quality Healthcare) is a centralized, non-profit database where healthcare providers store their credentialing information. It was created to reduce the redundancy of providers submitting the same credentialing documents to every payer separately.
More than 1,000 health plans and other healthcare organizations use CAQH to retrieve provider information during the enrollment process.
What CAQH contains:
- •Demographic information (name, address, specialty)
- •Licensure information
- •Education and training history
- •Work history
- •Malpractice insurance details
- •DEA and state controlled substance certificates
- •Hospital affiliations
- •References
CAQH profiles must be actively re-attested every 120 days to remain active. This confirms that the information in the profile is still current and accurate. A profile that has not been attested will be marked as "not authorized" by many payers, which can stop the enrollment process.
Missing CAQH attestation is one of the most common preventable causes of credentialing delays.
CAQH vs. actual enrollment:
CAQH ProView is a data repository — not an enrollment system. Completing your CAQH profile does not enroll you with any payer. It provides payers with the information they need to process your enrollment, but each payer requires a separate enrollment application.
What Is PECOS?
PECOS — Provider Enrollment, Chain, and Ownership System — is the CMS system through which healthcare providers enroll in Medicare. Every provider and supplier who wants to bill Medicare fee-for-service must complete enrollment through PECOS.
Who must enroll in PECOS:
- •All individual providers billing Medicare (physicians, NPs, PAs, therapists, etc.)
- •All organizations and group practices billing Medicare
- •Suppliers of durable medical equipment, prosthetics, and orthotics (DMEPOS)
- •Individual provider enrollment (Type 1 NPI)
- •Group/organization enrollment (Type 2 NPI)
- •Linking individual providers to the group entity
- •Delegating enrollment authority (for group administrators)
- •Changes of information (address, ownership, reassignment)
- •Voluntary withdrawal and reactivation
- •Medicare revalidation
Medicare requires all enrolled providers and organizations to revalidate their enrollment information periodically — typically every 3–5 years. CMS sends revalidation notifications by mail and email. Missing a revalidation deadline results in the provider's Medicare billing privileges being deactivated.
PECOS and CAQH are separate:
CAQH is not connected to PECOS. Your CAQH profile does not affect your Medicare enrollment, and your PECOS enrollment does not update CAQH. These are entirely separate systems.
How NPI, CAQH, and PECOS Work Together
Here is how these three systems interact in the typical enrollment workflow:
For commercial payer enrollment:
For Medicare enrollment:
For Medicaid enrollment:
How to Set Up Each System
Setting up your NPI:
- •Visit nppes.cms.hhs.gov
- •Create an account and apply for a Type 1 NPI
- •If starting or joining a group, apply for a Type 2 NPI for the entity
- •Select the correct taxonomy code(s) for your specialty
- •NPI is issued typically within 1–5 business days
- •Request a CAQH authorization number from a participating payer or directly from CAQH
- •Register at proview.caqh.org
- •Complete all sections including licensure, education, work history, and malpractice
- •Upload required documents
- •Attest the profile to authorize payers to access it
- •Re-attest every 120 days to keep the profile active
- •Access PECOS through I&A (Identity and Access Management) at identity.cms.gov
- •Create an account and complete Identity Verification
- •Submit a Medicare enrollment application for each NPI (individual and group)
- •Provide documentation as requested
- •Monitor application status through PECOS
Common Issues and How to Fix Them
NPI record issues:
- •Wrong taxonomy code → Update NPPES immediately; taxonomy must match what you will bill
- •Wrong address → Update NPPES; mismatched addresses cause enrollment delays
- •NPI deactivated → Contact NPPES help desk to understand the reason and reactivate
- •Profile not attested → Log in and attest; payers cannot access unattested profiles
- •Outdated documents → Upload current malpractice certificate, license, and DEA
- •Profile shows errors → Review each section carefully; inconsistencies trigger delays
- •Forgotten login → Use CAQH help desk to recover access
- •Revalidation missed → Contact your MAC (Medicare Administrative Contractor) to understand next steps; deactivated providers typically must file a new PECOS application
- •Individual not linked to group → Submit a reassignment of benefits form in PECOS
- •Address not updated → Update PECOS when your practice location changes; this affects your Medicare billing privileges
Frequently Asked Questions
How often do I need to update my CAQH profile?
You must attest your CAQH profile at least every 120 days to keep it active. Beyond attestation, you should update your profile any time information changes — new license, renewed malpractice certificate, new address, new hospital affiliation, or any change to your background. Stale CAQH profiles cause preventable enrollment delays.
What is a PTAN and how is it different from an NPI?
An NPI (National Provider Identifier) is a universal identifier used to identify providers across all healthcare transactions. A PTAN (Provider Transaction Access Number) is a Medicare-specific identifier issued to providers upon completion of PECOS enrollment. You need your PTAN to bill Medicare. Your NPI is used broadly across all payers; your PTAN is specific to Medicare.
Can I delegate someone else to manage my CAQH and PECOS?
Yes. Both CAQH and PECOS allow providers to authorize delegates — such as a practice administrator, office manager, or credentialing specialist — to manage their profile on their behalf. The provider retains ultimate responsibility for the accuracy of the information, but administrative access can be granted to someone else.
Does CAQH automatically submit my information to payers?
No. CAQH ProView allows payers to access your information when they are processing your enrollment application. Simply having a CAQH profile does not trigger any enrollment. You must still apply for enrollment with each payer separately, at which point the payer may pull your data from CAQH.